and Lori K. Holleran Steiker31Department of Psychology, Arizona State University, Tempe, Arizona 85287-1104;email: felipe.castro@asu.edu2Southwest Interdisciplinary Research Center, Arizona State University, Phoenix,Arizona 850043School of Social Work, University of Texas at Austin, Austin, Texas 78712

Annu. Rev. Clin. Psychol. 2010. 6:21339

First published online as a Review in Advance onJanuary 6, 2010

The Annual Review of Clinical Psychology is onlineat clinpsy.annualreviews.org

This articles doi:10.1146/annurev-clinpsy-033109-132032

Copyright c 2010 by Annual Reviews.All rights reserved

1548-5943/10/0427-0213$20.00

Key Words

cultural adaptation, adaptation models

AbstractThis article examines issues and challenges in the design of culturaladaptations that are developed from an original evidence-based inter-vention (EBI). Recently emerging multistep frameworks or stage mod-els are examined, as these can systematically guide the developmentof culturally adapted EBIs. Critical issues are also presented regardingwhether and how such adaptations may be conducted, and empiricalevidence is presented regarding the effectiveness of such cultural adap-tations. Recent evidence suggests that these cultural adaptations areeffective when applied with certain subcultural groups, although theyare less effective when applied with other subcultural groups. Generally,current evidence regarding the effectiveness of cultural adaptations ispromising but mixed. Further research is needed to obtain more deni-tive conclusions regarding the efcacy and effectiveness of culturallyadapted EBIs. Directions for future research and recommendations arepresented to guide the development of a new generation of culturallyadapted EBIs.

Clinical psychologists have a deep respectfor scientic principles that have contributedto the development of interventions and thesubstantiation of their effectiveness in relievinghuman suffering and remediating problems inliving. This research tradition has promoteddisciplinary standards of evidence for deter-mining that an intervention is efcacious inproducing one or more targeted outcomes

From the perspective of clinical practice,clinical psychologists have equal respect for anin-depth understanding of the person and ofhuman variation (Sue & Sue 1999). The essenceof the clinical method involves the applicationof nomothetic principles ltered through an

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individual case conceptualization and informedby clinical judgment for effectively treatingeach person. Within this duality, a dynamictension has emerged between the standardizednomothetic scientic top-down approach thatdemands delity in its implementation and theidiographic casewise bottom-up approach thatdemands sensitivity and responsiveness to eachpersons unique needs.

This dynamic tension can foment con-troversy, raise contentious issues, and launcha search for common ground. The culturaladaptation of evidence-based interventionsis a specic topic where these two equallyimportant professional values have clashed,particularly as embodied by the delity-adaptation dilemma (Castro et al. 2004, Elliott& Mihalic 2004). Within this context, weexamine the literature on treatment andprevention interventions; thus, we use the termevidence-based interventions (EBIs) to refer tointerventions of two types: (a) those developedto treat existing disorders, usually within clin-ical settings, i.e., evidence-based treatments(EBTs) and (b) interventions developed forpreventing disorders within various at-riskpopulations, i.e., evidence-based preventioninterventions (EBPIs).

The cultural adaptation of EBIs has emergedas an intervention strategy and will likely growin prominence as a result of two trends (LaRoche & Christopher 2008, Lau 2006): (a) thegrowing demand for EBIs and (b) the growingdiversication of the American population. Thegrowing demand for EBIs has emerged despiteclinicians concerns that it may be prematureand may impose unrealistic constraints on clin-ical practice (Bernal & Scharron-del-Ro 2001,Norcross et al. 2006).

Division 12 of the American Psychologi-cal Association (APA) has taken a leadershiprole in establishing criteria for determining thata psychological intervention is evidence basedand in maintaining a catalog of interventionsthat meet these criteria (Am. Psychol. Assoc.1995, 2006). Other groups, including the Na-tional Registry of Evidence-Based PreventionPrograms (NREPP) (Schinke et al. 2002), have

created such lists (Subst. Abuse Mental HealthServ. Admin. 2009). This demand has also beendriven by several professional groups, includingclinical researchers and scientist-practitionerswho feel a professional responsibility to developand deliver interventions supported by researchevidence. Other advocates include agencies thatpay for psychological services and civic, com-munity, and governmental organizations thatdemand evidence that limited funds will bespent appropriately on interventions that work(Whaley & Davis 2007).

The second trend involves the growing cul-tural diversity within the United States andthe globalization of intervention disseminations(Iwamasa 1997, Weisman et al. 2006). Unfor-tunately, the infusion of cultural factors intoEBIs and tests of their efcacy with subculturalgroups have not kept pace with these diver-sication trends. In this regard, La Roche &Christopher (2008) note that racial/ethnic mi-nority participants have rarely been includedin samples used for validating the efcacy ofEBIs, including many of those recognized byAPAs Division 12 in 1995 (Am. Psychol. Assoc.1995). This limitation has changed only mod-erately over the past decade.

PURPOSE AND SCOPE

The purpose of this review is to provide an anal-ysis of issues and challenges involved in the de-sign of cultural adaptations that are developedfrom original EBIs. We do so by pursuing twoaims. First, we review fundamental approachesand frameworks for a deep structure analysis ofculture, as tools for designing cultural adapta-tions of EBIs. Second, we identify and discusscritical issues and challenges in the design ofthese cultural adaptations. The analysis of theseissues is guided by the following four questions:

Are cultural adaptations developed fromoriginal EBIs justiable?

What procedures should intervention de-velopers follow when conducting a cul-tural adaptation?

What is the evidence that cultural adap-tations are effective?

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How can within-group cultural variationbe accommodated in a cultural adapta-tion?

In our analysis, we take a contemporaryview of clinical psychology science and prac-tice by including evidence from prevention in-terventions and from clinical psychotherapiesfor psychological disorders. We include preven-tion interventions because they also introduceimportant issues involving cultural adaptations(Munoz 1997). Finally, this review presents asummary of what we know about the culturaladaptation of EBIs, examines issues and chal-lenges, and presents suggestions for future re-search along with a few recommendations.

PERSPECTIVES ANDCHALLENGES IN THE DESIGNOF CULTURAL ADAPTATIONS

Several issues and challenges emerge in de-veloping a cultural adaptation of an EBI. Arst challenge involves the conceptualizationof culture in the design of an adapted EBI thatis tailored to the needs of a particular culturalgroup. Cultural adaptation involves a planned,organized, iterative, and collaborative processthat often includes the participation of personsfrom the targeted population for whom theadaptation is being developed. The culturalcompetence of the investigator and of thecultural adaptation team is also important forconducting a deep structure analysis (Resnicowet al. 2000) of the needs and preferences ofa targeted cultural group. Resnicow and col-leagues (2000) indicate that cultural sensitivityin developing tailored prevention interventionsconsists of two dimensions: surface structureadaptations and deep structure adaptations.According to Resnicow and colleagues, surfacestructure adaptations involve changes in anoriginal EBIs materials or activities thataddress observable and supercial aspectsof a target populations culture, such as lan-guage, music, foods, clothing, and relatedobservable aspects. By contrast, deep structureadaptations involve changes based on deeper

cultural, social, historical, environmental, andpsychological factors that inuence the healthbehaviors of members of a targeted population.

Concepts of Culture andCultural Frameworks

Culture is a complex construct, as indicatedby over 100 varied denitions of culture thathave been proposed (Baldwin & Lindsley 1994).Fundamentally, culture consists of the world-views and lifeways of a group of people. Munoz& Mendelson (2005) add that human phenom-ena can be construed at three conceptual levels:(a) universal characteristics that tend to applyto all people, (b) group-focused characteristicsand norms that apply to special cultural groups(or subcultural groups), and (c) individualizedcharacteristics that are unique to the individualperson.

A distinct group of people (a tribe, an eth-nic group, professional organization, a nation)can be described as having a culture, mean-ing that its members share a collective systemof values, beliefs, expectations, and norms, in-cluding traditions and customs, as well as shar-ing established social networks and standardsof conduct that dene them as a cultural group(Betancourt & Lopez 1993). Their cultural her-itage is transmitted from elders to children, andit confers members of this cultural group witha sense of peoplehood, unity, and belonging, acollective identity or ethnicity (McGoldrick &Giordano 1996). Language is a distinct facet ofculture that encodes symbols, meanings, formsof problem solving, and adaptations that alsofacilitate the groups survival (Harwood 1981,Thompson 1969 as cited by Baldwin & Lindsley1994).

Although culture is a complex construct, itcan nonetheless be applied in the design andcultural adaptation of an original EBI. A chal-lenge in this application involves problems thatemerge when equating culture with ethnicityand/or when using ethnicity or nationality asproxy variables for culture. Culture and ethnic-ity are not synonymous (Betancourt & Lopez1993), and developing a cultural adaptation

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does not necessarily involve the developmentof an ethnic adaptation.

Population Segmentation

An emerging challenge in designing a cul-turally relevant adaptation of an original EBIinvolves reframing this adaptation under a unitof analysis other than ethnicity. In this regard,population segmentation (Balcazar et al. 1995)narrows an otherwise heterogeneous ethnicpopulation or group into a smaller and morehomogeneous subcultural group to avoid eth-nic gloss in planning an intervention (Resnicowet al. 2000, Trimble 1995). As an example ofthis approach, as minority youths are dispro-portionately overrepresented within juvenilejustice settings, being under adjudication canoperate as a salient factor that better denesthe common life experiences of a certainsubcultural group of deviant youths. Thissubcultural group can consist of youths fromdiverse racial/ethnic backgrounds (AfricanAmericans, Latinos, white nonminority) whoshare several common developmental andfamilial experiences (i.e., disrupted families,antisocial conduct, and experiences of incarcer-ation or rehabilitation). Thus, their commondevelopmental trajectories can establish thismultiethnic group of deviant youths as a sub-cultural group of adolescent juvenile offenders.This example illustrates how investigators mayreframe their perspective on culture by address-ing a common cultural identity, such as adjudi-cated youths, as the cultural unit of analysis forthe design of a culturally relevant adaptation, inplace of focusing on the label of ethnicity per se.

Subcultural Groups

In the United States there exists considerableheterogeneity within and between major racial/ethnic groups: Latinos/Hispanics, AfricanAmericans, Asian Americans, NativeAmericans. These racial/ethnic groups rangein population size from about one millionamong Native Americans to over 42.7 millionfor Hispanics/Latinos (U.S. Census Bur. News2006). Within each of these broad racial/ethnic

groups, there exist many homogeneous sub-cultural groups, hidden subpopulations thatcan be dened by population segmentation(Balcazar et al. 1995). This approach canexamine the intersection of cultural elements(Schulz & Mullings 2006) such as nationality,socioeconomic status, religious background,immigration status, gender, and generationalgroup, as well as any special identity or socialstatus, such as being under adjudication. Wediscuss aspects of this segmentation approachlater in this review.

The Structure of Culture as aCollection of Cultural Elements

Chao & Moon (2005) introduced the culturalmosaic as a structural framework consisting ofa collage of elements that constitute a personssociocultural identity. The identity of each indi-vidual consists of a unique combination of ele-ments (or cultural tiles), including demographic(e.g., age, race, ethnicity, gender), geographic(e.g., urban-rural status, region or country), andassociative (e.g., family, religion, profession). Asan extension of this framework, an ethnic groupconsists of a collective of individuals who sharemany common elements (e.g., a common her-itage, religion, or ethnic identity). Accordingly,members of this group share a common groupidentity, although each individual also differsfrom the others in his or her unique combina-tion of cultural tiles.

This mosaic may appear complex, yet uponcloser inspection it exhibits a coherent andidentiable structure. This integrative systemicapproach describes the complexities of cul-ture within its natural ecological context andalso captures the perspective of anthropologistsKluckhohn and Murray, who stated that everyperson is like all other people, some other peo-ple, and no other person (Kluckhohn & Murray1948).

Systemic-Ecological Modelsof Culture

Erez & Efrat (2004) proposed a multilevelmodel of culture that features both structural

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and dynamic elements. Structurally, these lev-els of culture range from the most macro(global culture) to the most micro (the in-dividual person). An earlier version of thissystemic model, Bronfenbrenners ecodevelop-mental model (Bronfenbrenner 1986) intro-duced the macro, exo, meso, and micro ecolog-ical levels. This model describes how events ateach of these levels can inuence an adolescentsidentity development and behaviors. From a dy-namic perspective, temporal inuences on in-dividual behavior and development can also beexamined systemically, e.g., how parents inu-ence a childs development over time. This mul-tilevel model is similar to other more recentsystemic ecodevelopmental models that havebeen proposed (Castro et al. 2009, Szapocznik& Coatsworth 1999). Erez & Efrat (2004) alsoadvocate for a shift from conceptions of cultureas a stable entity toward a conception of cul-ture as a dynamic entity that exhibits multipleinuences across time and ecological levels.

Cultural Change andAcculturative Adaptation

A major concept in the analysis of culture andcultural change is acculturation. Acculturationis a worldwide phenomenon that occurs whenindividuals and families migrate from onesociocultural environment to another in questof better living conditions. Early concep-tions of acculturation regarded it as a linear,unidirectional process, although more contem-porary frameworks emphasize two dimensions:an orientation to the new host culture (themainstream culture) and an orientation to thenative culture (the ethnic culture) (Oetting& Beauvais 19901991). This two-factorconceptualization, however, is not without itscriticisms (Rudmin 2003). Under this two-factor framework, variations in acculturativeoutcomes include a bicultural/bilingual iden-tity (Berry 1994, Cuellar et al. 1995, Marin &Gamboa 1996) as well as complete assimilationinto the mainstream culture.

A deep structure understanding of culturalchange and adjustment can inform intervention

adaptations so that they address issues of ac-culturation change, as these may increase riskbehaviors among some members of a subcul-tural group. Acculturation stressors in familialand social contexts have been associated withhigher rates of substance use (Vega et al. 1998),implicating the erosion of native culture familyvalues, attitudes, and behaviors (Gil et al. 2000,Samaniego & Gonzales 1999). Other studies ofacculturative stress among African Americans(Anderson 1991) have also alluded to the ero-sion of Afrocentric values that may reduce fa-milial protections against substance use.

Cultural Relevance andCultural Adaptation

To the extent that an EBI lacks relevance to thecultural needs and preferences of a subculturalgroup (i.e., beliefs, values, customs, traditions,and lifestyles), that intervention may receiveunfavorable responses from these participants.When compromised by low participation rates,that EBI will likely exhibit a loss in effectiveness.This intervention phenomenon has promptedthe emergence of a principle of cultural rele-vance (Castro et al. 2004, 2007; Frankish et al.2007). This principle indicates that an EBI thatlacks relevance to the needs and preferencesof a subcultural group, even if the interven-tion could be administered with complete -delity, would exhibit low levels of effectiveness.This principle also suggests that an interven-tion developer must develop a deep structureunderstanding of a subcultural groups culture(Resnicow et al. 2000) in order to develop a cul-turally relevant and effective EBI.

By contrast, high consumer responsivenessand participation would be expected for an in-tervention that is high in cultural relevanceas characterized by (a) comprehension: under-standable content that is matched to the linguis-tic, educational, and/or developmental needs ofthe consumer group; (b) motivation: contentthat is interesting and important to this group;and (c) relevance: content and materials thatare applicable to participants everyday lives(Castro et al. 2004).

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Terminology for ApproachingCultural Adaptation

Another challenge is the choice of strategy inthe design of a cultural adaptation of an EBI.The concepts and terminology used in plan-ning an adaptation will inuence this strategy.Three terms have been used to describe ef-forts to incorporate culturally relevant contentinto an intervention: culturally adapted, cultur-ally informed, and culturally attuned. In a lu-cid commentary, Falicov (2009) described cul-tural adaptations to EBIs as procedures thatmaintain delity to the core elements of EBIswhile also adding certain cultural content tothe intervention and/or its methods of engage-ment. She saw cultural adaptations as a mid-dle ground between two extreme positions:(a) a universal approach that views an origi-nal EBIs content as applicable to all subcul-tural groups and, therefore, not in need of alter-ations, and (b) a culture-specic approach thatemphasizes unique culturally grounded con-tent consisting of the unique values, beliefs,traditions, and practices of a particular sub-cultural group. From this middle ground, cul-tural adaptation may draw criticism from bothextremes by proposing alterations regarded asdeviations from delity. Thus, from one per-spective, it goes too far; conversely, from theother perspective, it lacks sufcient integra-tions of cultural perspectives and thus does notgo far enough. Falicov (2009) observed thatcultural adaptations are based on the premisethat

. . .the core components of a mainstream formof treatment should be replicated faithfullywhile adding-on certain ethnic features. Thisassumption must be based on the idea thatthe core components are culture-free andeven more problematically, that the theoryof change involved is universally powerful(p. 295).

Bernal and colleagues have dened culturaladaptation as the systematic modication of anEBT (or intervention protocol) to consider lan-guage, culture, and context in such a way that it

is compatible with the clients cultural patterns,meanings, and values (Bernal et al. 2009).

The term culturally informed interven-tion might convey a sense that culture is amore primary consideration than it is in cul-tural adaptations (Falicov 2009), although thatdistinction is not widely acknowledged. Inter-vention development studies sometimes favorthe term culturally informed over culturaladaptation (e.g., Santisteban & Mena 2009,Weisman et al. 2006). For example, CulturallyInformed Therapy for Schizophrenia, a family-based therapy, was piloted with Latinos livingin Miami and added specic modules on keycultural components such as collectivism andspirituality (Weisman et al. 2006). More com-mon topics that might be found in other family-training interventions such as communicationand problem solving also were included.

Cultural attunement is a term that wascoined by Falicov (2009) to refer to additionsto evidence-based therapies that are intended toboost engagement and retention of subculturalgroups in treatment. This terminology and ap-proach focuses on the process of interventiondelivery rather than on intervention content.Providing services in clients native language,including familiar cultural traditions, and uti-lizing bicultural staff are examples of featuresthat might attract subcultural groups into treat-ment and increase their comfort in sustainedparticipation. The additional implication hereis that attunement is a surface structure adap-tation that does not modify core interventioncomponents that were designed to affect ther-apeutic change mechanisms or outcomes.

In reality, there exists a continuum amongcultural adaptations that varies between the ex-tremes of making no alterations to an originalEBI in its application to a subcultural groupand the complete rejection of the EBI in favorof a novel, culturally grounded approach thatis developed in collaboration with the intendedconsumers. In between those two extremes arealterations that change few or many of the fea-tures of an intervention to affect engagementand/or the interventions core components thatinuence mediating mechanisms of change.

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PROFESSIONAL CONTEXTSAFFECTING THE DESIGN OFCULTURAL ADAPTATIONS

Distinctions Regarding Types ofEvidence-Based Interventions

Evidence-based treatment and evidence-based practice. In addition to the noted vari-ation in terminology and approach to inter-vention adaptation, there are two approachesto the application of research evidence, i.e.,evidence-based treatment (EBT) and evidence-based practice (EBP) (Kazdin 2008). EBT refersto the specic interventions or techniques, suchas cognitive therapy for depression, that haveproduced therapeutic change as tested withinclinical trials. By contrast, EBP is seen as abroader term that refers to clinical practicethat is informed by evidence about interven-tions, clinical expertise, and patient needs, val-ues, and preferences and their integration intodecision-making about individual care (Kazdin2008, p. 147). As in the realm of culturaladaptations, in reality a continuum exists be-tween the extremes of EBT and EBP, and of-ten these boundaries blur. From a somewhatbroader perspective, the APA 2005 Presiden-tial Task Force on Evidence-Based Practice,dened evidence-based practice in psychology(EBPP) as the integration of the best avail-able research with clinical expertise in the con-text of patient characteristics, culture, and pref-erences (Am. Psychol. Assoc. 2006, p. 273).From this perspective, in addition to empiricalresearch evidence, clinical expertise is also re-garded as a viable source of evidence that canguide the development of clinical interventions.

Clinical practice is characterized by theapplication of clinical experience and judgmentto alleviate a specic presenting problem aseffectively as possible (Am. Psychol. Assoc.2006). On a practical level, one ongoingconcern involves the extent to which clinicianscan and actually do utilize the results of clinicalresearch to guide their clinical interventions.Some clinicians have been skeptical about theclinical applicability of certain EBIs, especially

when intervention procedures have beenincorporated into a treatment manual (Duncan& Miller 2006).

Evidence-based intervention treatmentmanuals. Treatment manuals describe anintervention in sufcient detail so that thepractitioner can appropriately implement corecomponents in treatment delivery (Addis &Cardemil 2006) and produce targeted treat-ment outcomes, provided that the treatment isconducted with adherence to the manualizedtechniques and activities. Despite some criti-cisms about the reputed rigidity of treatmentmanuals, well-constructed treatment manualshave been described as not rigid and, to thecontrary, afford therapists exibility and allowdiscretionary decision making under a seriesof dialectics that encourage (a) balancingadherence to the treatment manual versusclinical exibility and (b) balancing attentionto the therapeutic relationship versus attentionto therapeutic techniques (Addis & Cardemil2006).

Also, the greater the therapists experience,the greater the range of exibility that thetherapist can exercise in applying clinicaljudgment in response to a clients uniqueneeds. The experienced therapist may be seenas conducting a single-case cultural adaptationwhen tailoring an EBI to the unique needsof a particular racial/ethnic minority client.This exibility is likely pervasive within dailyclinical practice, although it raises questionsabout the limits of exibility that a therapistmay exercise. How can a therapist tailor theoriginal EBI in response to the unique culturaland treatment needs of any individual minorityclient while also adhering to an EBIs manual-ized tested-and-effective therapeutic principlesand methods (Addis & Cardemil 2006)?Within this context, examples exist of adap-tations of EBIs that were not effective whendeviating from core procedures contained inthe original EBI (Kumpfer et al. 2002), thusraising concerns about a loss of efcacy whendeviating signicantly from the established

Core issues affecting cultural adaptations.A fundamental controversy in this eld ofadaptations is the delity-adaptation dilemma,which consists of a dialectic involving argu-ments favoring delity in the delivery of anEBI as designed versus arguments favoring theneed for adaptations to reconcile intervention-consumer mismatches in accord with the needsand preferences of a subcultural group (Bernal& Scharron-del-Ro 2001, Castro et al. 2004,Elliott & Mihalic 2004). There are reasoned ar-guments on both sides of the delity-adaptationissue. On the one hand, intervention re-searchers spend years developing, rening, andtesting the efcacy of a theory-based and struc-tured intervention, thus recommending that itbe administered with high delity to the inter-vention procedures as designed. This view isthat efcacy is best attained under strict adher-ence to the interventions procedures as testedand validated; there should be no compromises(Elliott & Mihalic 2004). By contrast, if anintervention lacks relevance and t with theneeds and preferences of a specic subculturalgroup (an intervention-consumer mismatch) orwithin diverse ecological conditions, then cer-tain adaptations are usually necessary.

Castro et al. (2004) developed a tablethat shows the possible sources of mismatchthat can occur between a program validationgroup and the current consumer group (seeTable 1). These specic sources are presentedunder three domains: (a) group characteristics,(b) program delivery staff, and (c) administra-tive/community factors. The general adapta-tion strategy is to identify specic sources ofintervention-consumer mismatch and then to

introduce specic adaptive elements or activi-ties that resolve each of these sources of mis-matches to enhance relevance and t.

CONCERNS OVER EROSIONOF INTERVENTIONEFFECTIVENESS

The distinction between efcacy and effective-ness is central to the aims of cultural adapta-tion. Whereas efcacy measures how well anintervention works when tested within the con-trolled conditions under which it was designed,effectiveness measures how well the interven-tion works in an applied, real-world setting(Flay et al. 2005, Kellam & Langevin 2003).Due to the greater challenges in the applicationof a tested-and-effective intervention in com-plex real-world settings, level of effectiveness, asmeasured by effect size, is almost always smallerrelative to efcacy. The challenge involves sus-taining the full intervention effects of the vali-dated intervention when transitioning from labto community. Similarly, this aim of maintain-ing the full intervention effects is central in thetransition from the original EBI to an adaptedEBI.

One other consideration regarding inter-vention efcacy and effectiveness involves thecriterion of effectiveness, as dened in refer-ence to a specic population or group. This cri-terion is that A statement of efcacy should beof the form that, Program or policy X is ef-cacious for producing Y outcomes for Z pop-ulation. (Flay et al. 2005, p. 154). In otherwords, for many interventions, a general state-ment regarding the universal effectiveness ofan intervention for all people and outcomes isessentially meaningless. This criterion for ef-fectiveness refers to the external validity of theoriginal EBI and the role of a cultural adap-tation, given that the effectiveness of an EBIshould be dened in relation to the population(or populations) with which it was tested; effec-tiveness remains undened or is indeterminatein relation to a population that is signicantly orculturally different from the original validationpopulation.

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Table 1 Sources of intervention-population mismatch

Source of mismatch Original validation group(s) Current consumer groupActual or potential mismatch

A history of objections to the 1995 TaskForce on Promotion and Dissemination of Psy-chological Procedures notes that some haveviewed this report as reecting a double stan-dard (Bernal & Scharron-del-Ro 2001). The

report appeared to endorse the use and dis-semination of EBIs under the premise that ad-equate support exists regarding their efcacy.Nonetheless, it was apparent that the founda-tion research had limited external validity ow-ing to the limited inclusion of diverse samples toestablish intervention efcacy with these vari-ous constituencies. In the absence of sufcient

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Awareness of

treatment availability

Entry into treatment

Participation in treatment

activities

Completion of

treatment

Treatment participants

Evidence-based

treatment

Common mediator (supportive parenting)

Unique mediator

(immigration stress)

Common outcome (depression)

Unique outcome

(immigration distress)

OutcomesEngagement

Action theory Conceptual theory

A

B

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Figure 1A heuristic framework for the cultural adaptation of interventions.

evidence that an EBI is effective for a partic-ular subcultural group, some scholars have ar-gued that cultural adaptations or even novel cul-turally grounded treatments are justiable andeven necessary.

Lau (2006) has provided a thoughtful anal-ysis of the issue of when to develop a culturaladaptation for an EBI. She advocated a theory-and data-driven selective and directed approachfor determining whether an EBI should be cul-turally adapted and, if so, which treatment ele-ments might be altered. In a related approach,Barrera & Castro (2006) developed Figure 1in their commentary on the Lau (2006) arti-cle to illustrate the features of an interven-tion that might be considered for adaptation.The cultural adaptation of an original EBI isjustied under one of four conditions: (a) in-effective clinical engagement, (b) unique riskor resilience factors, (c) unique symptoms of

a common disorder, and (d ) nonsignicant in-tervention efcacy for a particular subculturalgroup.

Ineffective engagement. As shown inFigure 1, during the engagement stage, arst justication for an adaptation is thatan intervention exhibits deciencies in itsability to engage clients from a particularsubcultural group relative to rates of engage-ment found for other groups. The variousforms of engagement include (a) awareness oftreatment availability, (b) entry or enrollmentinto treatment, (c) participation in treatmentactivities, (d ) retention and completion oftreatment (see Figure 1, paths A, B, C, D). In(e) prevention interventions, this includesactive outreach to a targeted group to mobilizetheir participation. In prevention interven-tions, attracting and retaining the participation

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of community residents and/or members ofhigh-risk subcultural groups remains oneof the greatest challenges in the design andimplementation of efcacious and successfulprevention-related EBIs.

Unique risk or resilience factors. A secondjustication arises when the original EBI showsdiminished efcacy because a subcultural groupdemonstrates unique risk or resilience factorsthat are related to a clinical outcome. This istantamount to suggesting that certain subcul-tural groups exhibit different etiological pro-cesses that inuence the occurrence and courseof a common disorder. Such culturally specicmechanisms would suggest the need to add newand efcacious intervention components thatare different from the original core componentsin order to prevent or change the occurrenceand/or severity of a targeted disorder. One hy-pothetical example is an EBI for childhood de-pression developed initially for children withno experience with immigration stressors. If ev-idence for a new subcultural group (e.g., thechildren of immigrants) suggests that immigra-tion stressors are related to childhood depres-sion, an adaptation of the original EBI that addsa unique adaptive component to buffer the ef-fects of immigration stressors would be justied(see path X in Figure 1).

Research evidence on risk factors can alsosuggest the modication or deletion of certaincore intervention elements or components thatdo not contribute to improving targeted out-comes. A multistudy project by Yu & Seligman(2002) provided an example of the culturaladaptation of a prevention program for youthsin Beijing, China, that modied original corecomponent material on assertiveness in orderto accommodate local cultural norms and ex-pectations. These investigators cited researchsupporting their view that low assertiveness wasless of a risk factor for the Chinese children ascompared with Western children. Within thisChinese cultural context, culturally assertiveinteractions of Chinese children with theirparents were qualitatively different from theassertive interactions of their Westernized

peers with their parents. This cultural contextprompted the design of a modied adaptationcomponent that was culturally responsive tothese cultural differences involving the form,meaning, and risk potential of low assertiveness.

Unique symptoms of a common disorder.A third situation that justies cultural adapta-tions is when a subcultural group shows uniquesymptoms that are associated with a commondisorder (see path Z in Figure 1). Lau (2006)illustrated this condition by describing researchthat showed that southeast Asian refugees hadunique manifestations of panic attacks that wereameliorated when specialized treatment proce-dures were added (Hinton et al. 2005). Theidentication of unique risk/resilience factorsand unique symptom features can be accom-plished by a careful review of basic epidemio-logical research or by new studies (e.g., Yu &Seligman 2002).

Nonsignificant intervention efficacy. Afourth justication for the cultural adap-tation of an intervention is provided whenan EBI is implemented with delity with asubcultural group, yet the quantitative resultsreveal less-effective outcomes, as indicated byattenuated effect sizes. As one example, anadapted version of a preventive interventionfor depression (the Penn Resiliency Program)was tested with Latino and African Americanyouths in Philadelphia (Cardemil et al. 2002).Results showed that the intervention wassuccessful in reducing depression symptomsfor Latinos, but the intervention did not affectthe hypothesized mediating mechanisms ordepression for African American youths. Thedata indicated that this intervention requiredadditional adaptive elements to be effectivewith African American children.

An entirely new intervention. A fth con-dition that extends well beyond adaptationis a case where an entirely new interventionis proposed. Such an extreme option wouldbe justiable and necessary when no relevanttreatment exists to meet the unique needs of a

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particular subcultural group. Given the prolif-eration of scores of treatment and preventioninterventions now available, it is difcult tojustify the development of an entirely newintervention. A preferable approach would beto identify a closest-tting EPI for a particularsubcultural group and then consider thevarious aforementioned approaches to culturaladaptation.

The growing need for cultural adaptations.In their conclusions regarding the state of sci-ence on psychosocial interventions for ethnicminorities, Miranda and colleagues (2005) in-dicate that a question that remains unansweredinvolves the extent to which interventions needto be culturally adapted to be effective withminority populations. This question shouldbe reframed, in part, to accommodate theconsiderable within-group variation that existswithin each of the four major racial/ethnicminority populations of the United States:Latinos/Hispanics, African Americans, AsianAmericans, and Native Americans. When theunit of analysis is the total population of agiven ethnic/racial group, e.g., Latinos, theanswer to this question depends on the culturalcharacteristics of the particular targeted sub-cultural group. For example, among Latinos,the most basic form of cultural adaptation,linguistic adaptation (translation from Englishto Spanish; Castro et al. 2004), is unnecessaryand is not relevant for high-acculturatedLatinos, whereas it is absolutely necessary forlow-acculturated Latinos. By contrast, beyondthis instance of a need for a linguistic adapta-tion, conducting a more substantive culturaladaptation requires that the interventionistcommand a deep-structure understanding ofthe needs and preferences of members of aspecic subcultural group to successfully adaptthe original EBI in response to these needs andpreferences.

Miranda and colleagues (2005) also identi-ed three core issues regarding future effortsto improve the quality and availability of inter-ventions for racial/ethnic minority populations.These issues involve (a) the need to consider

cultural context in the delivery of interven-tions; (b) the need for methodologies that tailorEBIs for specic subcultural groups, includingthe identication of cultural factors that areamenable to adaptation; and (c) the need formethods that will actively engage ethnic mi-norities in interventions, including outreach tothese populations and ways to deliver interven-tions on a larger scale (Miranda et al. 2005).

In summary, the applicability of an EBI to aparticular subcultural group can be ascertainedfrom a reasoned analysis of engagement factors,the theoretical models of unique and commonrisk factors, and the targeted outcome variables.An analysis of these factors can serve as the ini-tial stage of a planned, structured, and collabo-rative process for culturally adapting an originalEBI.

Stage models are prominent in the developmentand testing of new drugs, medical procedures,and psychosocial interventions (Rounsavilleet al. 2001). Several stage models also have beenproposed for the cultural adaptation of EBIs,and these introduce considerations that differfrom those that guide the development of newinterventions. Table 2 summarizes three mod-els and suggests how they converge and divergein content, comprehensiveness, and scope. Acritical aspect of these models is that they con-tain deliberate steps that guide intervention de-velopers in using qualitative and quantitative

6. Integration: create second draft of theadaptation from input of topical experts

7. Training: train staff to implementrened version of the adaptation

8. Testing: conduct pilot research andshort-term outcome study to evaluateefcacy of the adaptation

data to determine the need for a cultural adap-tation, the elements of the intervention thatmight be changed, and estimates of the effectsof intervention alterations.

These comprehensive stage models ofcultural adaptations are illustrated with specicinterventions: the Strengthening FamiliesProgram (Kumpfer et al. 2008) and HIV/AIDSprevention (McKleroy et al. 2006, Wingood& DiClemente 2008). The comprehensivenessof those models is understandable becausethese stages were intended for the national andinternational dissemination of the core inter-ventions. Activities such as assessing agencycapacity and staff selection are indicative ofthe models grounding in the practicalities ofbroad-scale dissemination. A recent article de-scribing the ADAPT-ITT model is particularlyvaluable because it contains specic descrip-tions of methods, including marketing researchstrategies that can be used at each stage (Win-good & DiClemente 2008). The ADAPT-ITTmodel was illustrated with applications toAfrican American women in Atlanta and Zulu-speaking adolescent women in Africa. This

model, which grew out of a public health tradi-tion, has considerable relevance for applicationsto more mainstream clinical psychology topics.

A simplied framework by Barrera & Castro(2006) contains the essential elements of com-prehensive adaptation models. It presents fourstages, consisting of (a) information gather-ing (review the literature to understand com-mon and unique risk factors and conduct focusgroups to assess perceived positives and nega-tives of the original EBI), (b) preliminary adap-tation design (develop recruitment strategiesand modify the intervention based on informa-tion gathered in step a), (c) preliminary adapta-tion tests (pilot test the modied recruitment,intervention, and assessment procedures), and(d ) adaptation renement (modify the interven-tion based on pilot results and subject the in-tervention to a full evaluation with quantitativeand qualitative data) to evaluate the efcacy ofthe adapted intervention.

This model was used in the adaptation ofa lifestyle intervention for adult Latinas whohad diabetes (Barrera et al. 2010). The pilottesting stage served as the most valuable step

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in the adaptation process, particularly becauseit contained mechanisms for ongoing feedbackfrom participants and intervention staff mem-bers. Similar stages were developed indepen-dently of the Barrera & Castro (2006) frame-work and illustrated in the adaptation of adepression preventive intervention for Latinofamilies (DAngelo et al. 2009).

Other models contain steps that are sub-sumed by models shown in Table 2. DomenechRodrguez & Wieling (2004) drew fromRogerss (2000) framework on the diffusion ofinnovations to propose a three-phase CulturalAdaptation Process Model. That model in-cludes the steps of (a) studying the relevant liter-ature, establishing a collaborative relationshipwith community leaders, gathering informationfrom community members on needs and inter-ests; (b) drafting a revision of the intervention,soliciting input from community members, andpilot testing; and (c) integrating the lessonslearned from the preceding phase into a re-vised intervention that could be used and stud-ied more broadly. These strategies include bothbottom-up and top-down approaches; thus, likethose in the other process models, they strikea balance between community needs and sci-entic integrity (p. 320).

These conceptual frameworks describe theprocesses that intervention developers can fol-low in designing, implementing, and evaluatinga culturally adapted EBI. Others have pro-vided guidance in identifying the interventioncontent that might be adapted. Hwang (2006)offered a psychotherapy adaptation and modi-cation framework and illustrated it with consid-erations that were made in adapting a cognitivebehavior therapy (CBT) for Asian Americanclients. The psychotherapy adaptation andmodication framework contains six generaldomains and 25 therapeutic principles that wereorganized within those domains. The domainsconsist of aspects of the entire psychotherapyenterprise that therapists should be aware ofwhen treating clients from subcultural groups:(a) dynamic issues and cultural complexities,(b) orientation of clients to therapy, (c) cultural

Thus, criticisms that there exist no frame-works for guiding the cultural adaptation of in-terventions are no longer valid. It is clear thatsignicant advancements have been made in es-tablishing systematic, data-driven, consumer-sensitive processes for determining if EBIsshould be adapted, how they should be adapted,and what the results of those adaptations are onengagement and intervention outcomes. Someof the published exemplars of those approachesreport only on results from pilot data with verysmall samples that offer encouraging results(e.g., Barrera et al. 2010, DAngelo et al. 2009,Matos et al. 2006), although larger-scale out-come studies will appear soon. It will be in-teresting to determine if cultural adaptationsthat were developed through such comprehen-sive, multistep processes will exhibit higherlevels of effectiveness, as compared with ear-lier adaptations that were conducted beforesuch process frameworks appeared in the litera-ture. A related question is whether the adaptedEBI, when compared with the original EBI,can offer value-added effects by exhibiting sig-nicantly better outcomes, including signi-cantly larger effect sizes on targeted outcomevariables.

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Issue #3: Is There Evidence thatCultural Adaptations are Effective?

At the present time, the best answer to thequestion regarding the effectiveness of cul-tural adaptations has been provided in a meta-analytic review by Griner & Smith (2006). Theyreviewed 76 published and unpublished studiesthat contained explicit statements that interven-tion content, format, or delivery was adapted,based on culture, ethnicity, or race. The re-view produced several important ndings:

1. Half of the studies used two to four typesof adaptation activities; 43% used ve ormore. The most common adaptation ac-tivities (84% of studies) involved the in-clusion of cultural values and concepts.This was followed by native languagematching of clients to therapists (74%),ethnic group matching of clients to ther-apists (61%), and treatment in clinics thatexplicitly served clients from diverse cul-tural backgrounds (41%).

4. Studies that explicitly described interven-tions in which therapists spoke the samenon-English language as clients had ahigher effect size (d = 0.49), as com-pared with studies that did not describelanguage matching (d = 0.21).

5. For studies that included Latino partic-ipants, average effect sizes from stud-ies of low-acculturated Latinos (mostlySpanish-speaking clients) were twice aslarge as the average effect sizes fromstudies in which the Latino participantsexhibited moderate levels of accultur-ation (bilingual/bicultural clients). Al-though the authors condence in this

observation was attenuated by the smallnumber of studies, they interpreted thispattern as suggestive evidence that low-acculturation participants are in greaterneed of a cultural adaptation and stand tobenet more.

This review provided suggestive evidencethat culturally adapted interventions are effec-tive. Some ndings pointed to the possibil-ity that clients who had the greatest need foraccommodations (i.e., low-acculturated, non-English-speaking adults) received the greatestbenet from such adaptations. Future researchstudies that are explicitly designed to evalu-ate particular intervention components and fea-tures may clarify if these components operateas new core components that enhance targetedintervention outcomes. The studies included inthis review were completed before 2005. Sincethat time, several journal special issues (Bernal2006, Bernal & Domenech Rodrguez 2009)and other noteworthy studies have been pub-lished that have added further support to theconclusion that culturally adapted interventionsare effective.

By contrast, Huey & Polo (2008) conducteda detailed review that, unlike Griner & Smith(2006), was restricted to just EBIs and researchthat involved ethnic minority children and ado-lescents. However, these investigators reacheda much less positive conclusion than did Griner& Smith (2006) about the evidence support-ing cultural adaptations. For example, one ar-gument in favor of cultural adaptations is thatEBIs are relatively ineffective for ethnic minor-ity clients. Huey & Polo (2008) reported that 5of the 13 studies that tested for treatment-by-ethnicity interactions found evidence of differ-ential treatment efcacy. Three studies foundthat the EBIs were more effective for ethnicminority children when compared with whitechildren, whereas two studies found the oppo-site pattern.

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Huey & Polo (2008) also looked for evi-dence that culturally responsive EBIs enhancedtreatment outcomes. They contrasted the ef-fect sizes from studies that were identied asculturally responsive with those that were not.A conservative denition resulted in 10 stud-ies that used culturally responsive treatmentsand 10 that used standard treatments. A moreliberal denition resulted in the classicationof 14 treatments as culturally responsive and 6as standard. Neither the conservative nor lib-eral classication methods resulted in signi-cant differences in effect sizes when culturallyresponsive treatments were compared to stan-dard treatments with ethnic minority children.However, the authors acknowledged the lackof statistical power for making such compar-isons. Also, as Griner & Smith (2006) noted, theneed for culturally adapted treatments might belower for children than for adults. Overall, onthe basis of the studies they reviewed, Huey &Polo (2008) concluded that the utility of cul-tural adaptation remains ambiguous (p. 293)and warrants more research.

In summary, evidence from these two meta-analytic studies is mixed regarding the efcacyof culturally adapted EBIs relative to the orig-inal EBI and regarding their effectiveness ingeneral. Is the glass half empty or half full?One way to interpret these results is to in-dicate that current evidence shows the perva-siveness of cultural adaptations that have beendeveloped from original EBIs. These adapta-tions are typically effective in general. Theyare often, but not always, as effective as theoriginal EBI and usually exhibit greater rel-evance to the needs of a targeted subculturalgroup.

Issue #4: How Can WideWithin-Group Cultural VariationBe Accommodated in a CulturalAdaptation?

It is ironic that cultural adaptations intended tocorrect the one-size-ts-all application of EBIsby creating an ethnic adaptation that applies tomost members of a given ethnic group can be

subjected to the criticism that they too do notadequately respond to the heterogeneity thatexists within that cultural group. Within a largepopulation, such as within the United States,a given ethnic minority group, e.g., Latinos,consists of many individuals who differ broadlyfrom each other on dimensions of acculturationand other cultural factors. How might a culturaladaptation be effective for such a diverse pop-ulation? One noted approach involves popula-tion segmentation (Balcazar et al. 1995), a vari-ation of market segmentation (Lefevre & Flora1988), that consists of identifying a smallerand more homogeneous subpopulation (or sub-cultural group) whose members have commonneeds and preferences that are more effectivelyaddressed with a focused cultural adaptationthat is tailored to this subcultural groups col-lective needs and preferences.

Another solution to this problem restswith intervention procedures that containstandardized decision rules for varying thecontent and dosage of treatment, dependingon the characteristics of particular sectors ofparticipants or groups, e.g., families. This isthe essence of adaptive intervention designs(Collins et al. 2004). The word adaptive isunavoidably awkward in the context of thisdiscussion about culturally adapted EBIs. Inmost outcome research studies, investigatorsseek to provide the same treatment contentsin the same number of sessions to all of theparticipants who are assigned to an interven-tion condition. This approach emulates therigors of experimental research designs, albeitat the expense of sensitivity to within-groupindividual variations in clinical and culturalneeds and preferences. In contrast, adaptive in-terventions are closer in form to individualizedclinical practice because they provide explicitguidelines for the delivery of different dosagesof intervention components depending on theunique needs of individual clients and based onevidence-based decision rules for determiningvariations in these dosages. Such specicdecision rules would also allow replicabilityin clinical practice and research, such thatwell-crafted decision rules could be developed

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to respond appropriately to the common needsof a well-specied group of clients.

Collins et al. (2004) provide examples fromthe well-known Fast Track project to illus-trate how an adaptive intervention might beused with children who vary in their need foracademic, behavior management, and familysupport components of the intervention. Suchadaptive approaches hold considerable promisein general, and particularly for cultural adapta-tions that would be applied with specic andsomewhat heterogeneous subcultural groups.The broad dissemination and application ofsuch adaptive intervention designs would re-quire the availability of a sufciently large actu-arial database that is drawn from a diverse set ofpopulations, from which evidence-based rulescan then be developed and ultimately appliedto a wide cross-section of clients. A related is-sue involves the cultural competence of the in-tervention developers and of the interventiondelivery staff. Cultural competence would beessential in developing culturally appropriatedecision rules from the accumulated actuarialevidence.

In the same spirit of adaptive interventions,Pina et al. (2009) has described a culturally pre-scriptive intervention framework that guidesthe tailoring of childhood anxiety interventionsdepending on the cultural features of the indi-vidual or family. Rather than applying a xed setof adaptation activities, their treatment man-ual describes a uniform set of guidelines to assistinterventionists in determining how to attendto language and other cultural considerations(e.g., familism) in tailoring the intervention.The Pina et al. (2009) study also illustrateshow their childhood anxiety treatment adapta-tion incorporates the eight cultural parametersdescribed by Bernal et al. (1995) and the ini-tial treatment development stage described byRounsaville et al. (2001). This approach is real-istic and actively addresses the conict betweendelity and t.

In summary, one feasible goal in the designof culturally adapted EBIs is to utilize pop-ulation segmentation to identify a more nar-rowly dened subcultural group, thus reducing

the within-group variability that exists withina large ethnic population. A second strategy isto develop adaptive intervention protocols thatare tailored to the individuals or subculturalgroups unique needs and preferences. Ideally,both segmentation and adaptive interventionapproaches can be used strategically to enhancethe intervention-consumer t and the resultingintervention effectiveness.

APPLYING CULTURALADAPTATION APPROACHES

Exemplars of Culturally GroundedCognitive-Behavioral Treatments

CBT approaches in the treatment of adultdepression are among the most heavily re-searched EBIs (Butler et al. 2006). Munoz andcolleagues at the Depression Clinic of SanFrancisco General Hospital have conducted anumber of studies on the cultural adaptation ofCBT for adult depression treatment and pre-vention (e.g., Kohn et al. 2002, Miranda et al.2003, Munoz & Mendelson 2005). Munoz &Mendelson (2005) describe how these interven-tions were built on the core principles of so-cial learning theory (behavioral activation, so-cial skills, and cognitive restructuring) and thenwere modied to be culturally sensitive throughve considerations: (a) ethnic minority involve-ment in intervention development, (b) culturalvalues, (c) religion and spirituality, (d ) accultur-ation, and (e) racism, prejudice, and discrim-ination. These manualized interventions havebeen used broadly with a variety of ethnic/racialgroups by a number of different investigativeteams in the United States and abroad, andthrough a variety of media.

Two studies conducted with CBT depres-sion treatment have special relevance for thisarticle. One was a small quasi-experimentalstudy that compared African American women(n = 10) who received the standard CBTgroup therapy through the Depression Clinicat San Francisco General Hospital with thosewho elected to participate in a group de-signed specically for African American women

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(n = 8) (Kohn et al. 2002). The adaptationadded four modules concerned with healthy re-lationships, spirituality, African American fam-ily issues, and African American female identity.Although formal statistical analyses were notperformed, women in the standard treatmentshowed a 5.9 prepost drop in Beck DepressionInventory scores, whereas women in the cultur-ally adapted group showed a 12.6 point drop.In our estimation, this was one of only threestudies that have compared a cultural adapta-tion to a standard intervention (Botvin et al.1994, Kohn et al. 2002, Szapocznik et al. 1986)and the only one that has shown any suggestiveevidence of the extra benets from the culturaladaptation. The possibility of additional bene-ts from adaptations to an intervention that wasalready modied to be culturally sensitive wasan encouraging outcome of this study. One lim-itation is the lack of statistical analyses, althoughthat dovetails with the small sample size. Otherlimitations can include design issues that alsocenter around these two aspects of a small study.

A second study (Miranda et al. 2003) con-sisted of a randomized trial that contrasted theCBT group therapy (n = 103) developed byMunoz and his colleagues with the same grouptherapy regimen supplemented with telephoneoutreach case management, i.e., CBT with sup-plemental case management (n = 96). Of the199 predominantly low-income participants,77 were Spanish speaking, 46 were AfricanAmerican, and 18 were Asian or American In-dian. Case managers worked with patients onproblems in housing, employment, recreation,and relationships with family and friends (Mi-randa et al. 2003, p. 220). Results showed thatpatients who received supplemental case man-agement were less likely to drop out of treat-ment and attended more treatment sessions ascompared with patients who received just theCBT group therapy. For Spanish-speaking pa-tients, those who received supplemental casemanagement reported fewer depressive symp-toms at the end of treatment than did those whoreceived CBT groups only.

The addition of the supplemental case man-agement component was prompted by the

socioeconomic hardships and daily stressorsobserved among members of this subculturalgroup and not by any particular cultural aspectof race or ethnicity. Nevertheless, this studyillustrates how a supplemental adaptation de-signed to increase participant engagement toa culturally sensitive treatment could produceenhanced benecial outcomes. It also illustratesthe importance of cultural competence amongthe intervention developers, as they aptly iden-tied and understood the most salient socio-cultural needs and preferences of members ofthis subcultural group and thus introduced asupplemental case management component toaddress these needs and enhance the originalEBI.

The evaluation of the effectiveness of thekeepin it REAL intervention also showed thatstudents from the experimental schools, rela-tive to the comparison schools, acquired higherlevels of drug resistance skills and adoptedmore conservative norms that eschew substanceuse; they also exhibited lower rates of alcoholuse and less positive attitudes toward drug use(Kulis et al. 2005). The keepin it REAL cur-riculum is now recognized as a model programby the Substance Abuse and Mental Health Ser-vices Administration and has been disseminatednationally and internationally.

In contrast to the positive results forMexican American and other Latino youths inArizona, when this intervention was exportedto Texas, the local Mexican American youthsresponded critically to the videos, expressingthat they could not relate to certain con-tent and activities that were depicted, such asbreak dancing, even though these videos incor-porated Mexican American youths as protag-onists (Holleran et al. 2005). This revelationprompted the need for a local adaptation of thekeepin it REAL intervention in accord withthe needs and preferences of youths who live inTexas communities (Holleran Steiker 2008).

As another example, based on of the needfor a developmental adaptation, the keepinit REAL curriculum was adapted for a fth-grade subcultural group. Using focus groups,the adaptation team consulted with teacherswho commented on the language, scenarios,and activities prior to the pilot studies. The cur-riculum development specialists then adapted

the existing curriculum over a six-month periodto make the lessons developmentally appropri-ate for fth-graders and added two lessons toenhance intervention effects. The fth-gradeversion utilized the same basic curriculum con-tent as the standard seventh-grade multiculturalversion. The adapted activities involved ad-justments in communication level/format andgreater concreteness in the presentation of con-cepts. Other adaptations addressed age-basedrelevance in the examples, including simplica-tion in language and concepts and more age-relevant ways to model and practice resistanceskills using realistic situations.

ISSUES, ANSWERS, ANDABIDING CHALLENGES

Regarding our current state of knowledge aboutthe cultural adaptation of EBIs, we summarizeand comment on answers to four major issuesas framed according to the four key questions.

1. Are cultural adaptations developed fromoriginal EBIs justiable? Generally, thecultural adaptation of EBIs appears jus-tiable when the original EBI exhibitsone of four types of diminished interven-tion effects. Cultural adaptations are jus-tied under the conditions of (a) ineffec-tive client engagement, (b) unique risk orresilience factors in a subcultural group,(c) unique symptoms of a common disor-der that the original EBI was not designedto inuence, and (d ) poor intervention ef-fectiveness with a particular subculturalgroup.

2. What procedures should intervention de-velopers follow when conducting a cul-tural adaptation? To guide the design andimplementation of a culturally adaptedEBI, we now have a variety of stagemodels, most of which exhibit similarstages for conducting a cultural adapta-tion of an EBI. Thus, the basic path-ways for planning and conducting cul-tural adaptations have now been chartedand involve variations of four stages:(a) information gathering, (b) developing

3. What is the evidence that cultural adap-tations are effective? The evidence forthe effectiveness of cultural adaptations ispromising but mixed. It appears that cul-turally adapted interventions are approx-imately as effective as the original EBI.Ideally, the adapted intervention wouldprovide a signicant increment of im-provement on targeted outcome mea-sures, although few studies have con-ducted direct comparisons of this effect.Accordingly, we do not have sufcientevidence to address this issue with cer-tainty, and this calls for future studies thatare designed to test this effect. This is-sue raises another challenge involving thecosts and benets of developing a cultur-ally adapted intervention. Is it worth thecost and effort of designing and evalu-ating such adaptations, if the effect sizes(and thus effectiveness) on targeted out-comes are approximately equal to thoseattained under the original EBI? Suchadaptations might provide demonstrablegains in consumer participation and sat-isfaction, but are these gains sufcient tomerit the effort and expense involved indesigning a cultural adaptation of an EBI?

4. How can within-group cultural vari-ation be accommodated in a culturaladaptation? Regarding responsiveness towithin-group variation, two classes ofanswers are evident. This problem ofwithin-group variation can be addressedby (a) population segmentation, which in-volves more narrowly dening a targetedsubcultural group (attenuating within-group variability), and (b) adaptive inter-ventions of various types.

Directions for Future Development

Direct comparisons between originalEBIs and adapted versions. In comparative

outcome trials, culturally adapted interventionshave usually been contrasted with a controlcondition and not with unaltered versionsof the original EBI (Griner & Smith 2006).In principle, the essential justication for acultural adaptation is its superiority to the orig-inal EBI in terms of participant engagement,targeted outcomes, or both. Comparativeresearch of this type is needed. Now thatinformative frameworks exist to guide thedesign of cultural adaptations of EBIs, it will beparticularly interesting to compare an originalEBI to a rigorously adapted EBI to evaluatepossible enhancements in the effectiveness ofthe adapted EBIs.

An ecodevelopmental approach to culturaladaptation. Given the emerging emphasis ofsystemic approaches in the conceptualizationand application of culture (Castro et al. 2009,Erez & Efrat 2004, Szapocznik & Coatsworth1999), the use of systemic models for adapta-tion planning and implementation is clearly in-dicated. A proposed cultural adaptation shouldconsider the inuences of various cultural ele-ments such as religion, gender, and social class(Am. Psychol. Assoc. 2006, Cohen 2009). In ad-dition, this adaptation should also consider theinuences of surrounding community and so-cioeconomic factors that can enhance or dimin-ish the effect of the EBI on targeted therapeu-tic outcomes. A systemic analysis of antecedentfactors, mediators, and outcomes and of waysto boost intervention effects would be useful inefforts to maximize the overall benets of suchadapted EBIs.

subcultural groups of Latino clients (low accul-turated, bicultural, and high acculturated) couldreveal that the inuence of a cultural element(e.g., the role of respetoa respectful demeanorutilized by the therapist or interventionist) pro-duces strong and signicant intervention effectsfor Latino subgroup A1 (e.g., low-acculturatedLatinos), yet produces no effect for Latino sub-group A2 (e.g., high-acculturated Latinos).

In this regard, intervention outcome re-search can be used not only to evaluate the ef-cacy of an intervention, but also to test theory(Howe et al. 2002). When cultural adaptationsare explicitly designed to inuence a culturalconstruct hypothesized as important for ther-apeutic change (to lower acculturative stress,increase trust in the therapist, or strengthencultural identity), such studies may test if the in-tervention was successful in changing that con-struct (action theory) and also if that changeaffected the outcome (conceptual theory) (seeMacKinnon et al. 2002).

Developing adaptive culturally adapted in-terventions. As noted above, adaptive inter-ventions offer different dosages of interventioncomponents to various types of clients, depend-ing on the needs of individual clients, underexplicit decision rules for determining varia-tions in dosages. The specication of an arrayof client-dosage decision rules would establishan intervention protocol that could be testedand replicated in clinical practice and in re-search settings. Such adaptive approaches holdconsiderable promise for prescriptive culturaladaptations that can be applied with multiplesubcultural groups. Moreover, a series of stud-ies on the effects of selected cultural moderatorvariables (e.g., acculturation, immigration ex-perience, religiosity) could further inform thedecision rules developed for these prescriptiveadaptive interventions.

Some Recommendations

Utilize available frameworks and stagemodels to guide the cultural adaptationprocess. Remarkable similarity exists in the

frameworks and stage models that have beendeveloped to systematically guide the culturaladaptation of EBIs, even though these appear tohave been developed independently (Barrera &Castro 2006, DAngelo et al. 2009, DomenechRodrguez & Wieling 2004, Kumpfer et al.2008, McKleroy et al. 2006, Wingood &DiClemente 2008). Collectively, these frame-works and models advocate the use of existingresearch that identies the presence of uniquerisk and resilience factors that should be con-sidered in intervention revisions. These ap-proaches all contain early steps that employ fo-cus groups, marketing research strategies, andthe formation of community partnerships thatallow potential consumers to inform the pro-posed intervention. All employ the integrationof qualitative and quantitative research meth-ods. After a step that involves preliminary re-visions, all approaches include pilot researchand another opportunity to learn directly frompeople who resemble the intended consumersof the proposed cultural adaptation. Ultimately,these stages lead to a rened intervention thatcan be implemented with delity in broader-scale outcome research. Based on preliminaryndings, these frameworks can be used to reneand implement effective cultural adaptations.

Specify core components and mechanismsof effect. The developers of an originalEBI, and those who propose an adaptationto that EBI, should present and describea theory-based model that species theirinterventions putative core components andits related mechanisms of effect on targetedoutcome variables. This theory-based analysisof expected core component effects andmechanisms, as illustrated by Barrera & Castro(2006), would inform users of the interventionand would help research scientists to under-stand the role of the intended componentsand their intended therapeutic effects. Thiswould involve a formal core componentsanalysis that utilizes the mediational anal-ysis model presented by MacKinnon et al.(2002) and/or that utilizes a logic modelapproach, as has been conducted within

Importance of cultural competence oftherapists and intervention agents. Finally,frameworks for guiding the process of cultur-ally adapting interventions often focus on in-tervention content rather than on the person-nel who deliver the interventions. Whether in

a treatment setting or in a community setting,the analyses by Bernal et al. (1995) and Hwang(2006) remind us that cultural competence andother clinical skills of the intervention agentsare essential for delivering effective culturallyadapted EBIs. Thus, one essential aspect of acultural adaptation should be the specicationof personnel skills and training for the culturalcompetence necessary to effectively implementthe culturally adapted EBI.

DISCLOSURE STATEMENT

The authors are not aware of any afliations, memberships, funding, or nancial holdings thatmight be perceived as affecting the objectivity of this review.

ACKNOWLEDGMENT

This article was supported by grants from the National Center on Minority Health and HealthDisparities: Grant Number P20MD002316-010003, Felipe Gonzalez Castro, Principal Investi-gator, and Grant Number P20MD002316-01, Flavio F. Marsiglia, Principal Investigator. Thecontent is solely the responsibility of the authors and does not necessarily represent the ofcialview of the National Center on Minority Health and Disparities or the National Institutes ofHealth.

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